1 ABORN ST - BPA-14-229 RPR FRONT PORCH 2ZC( — 1 s
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Uy"
Massachusetts State Building Code, 780 CMR SALEM
dJ RevisedHar 20/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Pe tt N lb
Building OIY&ial(Print Name ign e Date
SECTION ti SITE INFORMATION
1.1 P=ss*Address: 1.2 Assessors iNlap&Parcel Numbers '
I.la Is this an accepted street? a no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal C3On site disposal system 13
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP''
2.1 Owner'of Record:
me(Print) City,State,ZIP
No. and Street �— Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) di Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ Q "'� 1. Building Permit Fee:$ -Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ '
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. iblechmtical (HVAC) $ List: -
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ f.� C3 Paid in Full ❑Outstanding Balance Due:
(�4�►vT►z-n�a-n 2. c�.3 tL.� p� c.K- t�a P
SECTION 5:_ CONSTRUCTION SERVICES
5.11 Construction Super�v�i/s�tor License(CSL)
0O /�p S 3r- LicenseNumberExpiration Date
Name of CSL Holder
List CSL"type(see below)
No.and Sveet � Type escription
L9 l,57 (/f Ue, Unrestricted(Buildings tip to 35,000 cu. R.)
R Restricted 1&2 Family Dwelling
Citylfown,Slate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-7-79(� I Insulation
Telephone Email address D Demolition
5.2 Registered
lHome
,Improvement Contractor(HIC) 2 Z �
,ennaL�/B f/'bUl//Ya H[ Registration Number
�GExpiration Date
I-IIC Com my Name or IIC Registrant Name
Ori 4/vim 4 L /�t/it syf/r/
No.and Street
� ��.�+�p-,�7� n ! Email address
Ci /Town, State,ZIP 7 i !D Telephone 7/Y
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the de ' f the Is§uance of the building permit.
Signed Affidavit Attached? Yes ......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION;TO BE.COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT' -
I,as Owner of the subject property,hereby authorizer/// i�, G4
tq act on my behalf,in all matters relative to work authorized by this building permit application.
Pry ` �ti�`i
Print caner' Nvue(E Uc roramc Si nature)
SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.nuiss.gov,oca Information on the Construction Supervisor License can be found at www.ma;s.«ov'dns
2. When substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost"